Case study - mrs .w

CASE STUDY - MRS .WALLISON CALLAN KSDI 2014

WHAT WE ARE GOING TO DISCUSS TODAY

Clinical Dietician’s role at Wing Memorial

Thyroid function and Thyroid Storm

Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS)

Nutrition Support and Refeeding Syndrome

WING MEMORIAL HOSPITAL AND MEDICAL CENTERS

Located in Palmer, Mass

Fully accredited by the Joint Commission

Wing Memorial is a 74-bed hospital

Established in 1913

Provides emergency, medical, surgical and psychiatric services to residents of Palmer, Monson, Wilbraham, Ludlow, Belchertown and nearby towns.

ICU, Medical/Surgical, Parker North, Geriatric Psych

Four additional medical centers were built to provide out patient services to the community

RD ROLE AT WING MEMORIAL HOSPITAL

One RD manager, part-time Manages RD’s

Provides outpatient care

Bariatric program

Three part-time clinical RD’s Cover all four floors

See every patient

Daily triage

Write diet order, w/ MD cosign

ICE BREAKER

Think of a health scenario that you, a family member or family friend had to go through?

Were there a lot of surprises? Or did you know what to expect?

Was it overwhelming?

Did you feel like all of your questions were answered?

Did you feel like you could support your loved one? Be an advocate for yourself?

Were there things that you wished had gone differently? Better? The same?

Share?

Please keep these things in mind as I tell you the story of Mrs. W.

THE STORY OF MRS. W

Social History

85 year old widowed female

Lives with daughter and son-in-law

Uses a cane for assistance with ambulation

Nonsmoker, no known alcohol or illicit drug use

Has six children

No recent known falls

Past Medical History

Extensive past medical history

PATIENT INFORMATION CONTINUED

Past Surgical History

Laparoscopic cholecystectomy (2003)

Home Medications

Metoprolol tartrate, Keflex, Lisinopril/Hydrochlorothiazide

Medication Allergies: ? Penicillin, Amoxicillin (allergies reported from childhood - unknown exact response)

Diet History

Does not follow a certain diet at home

Food Allergies: chocolate, strawberries and seafood

PATIENT INFORMATION

Medical information prior to admission

12/20/13 Was seen by PCP for wound of left lower leg

12/20/13 Antibiotic therapy and pain medication were initiated

Patient’s family were unaware of the details of the infection and medical history because the patient would not let her family in the room during doctor’s visits.

HOSPITAL ADMISSION DAY (12/27/13)

Admit DX in ED: HYPERGLYCEMIA, SEPSIS

Patient not able to speak at the present time

Patient presents with lethargy, altered mental status

Chronic left leg wound infection

According to the patient’s daughter: Reduced PO-drinking frequent Ensure supplementation

Polydipsia

Polyuria

HOSPITAL ADMISSION DAY (12/27/13)

Hypoxic 85%

Fever 101

BP 110/90, low at times with systolic between 80-100

Atrial Fibrillation with rapid ventricular response up to 166 beats per minute

Hyponatremia 132 (normal 136-145 mEq/dl)

Hyperglycemia with an initial blood sugar of 1257 (normal 70-100 mg/dL)

CPK 286 (normal value 30-135 units/L)

WBC 13.6 (normal 5-10,000/ mm3)

Creatinine 2.2 (normal 0.5-1.1 mg/dL)

BUN 61 (normal 6-20 mg/dL)

HOSPITAL ADMISSION DAY CONTINUED

Chest x-ray

Does not show any acute disease with large goiter

Stabilized HR with Diltizem between 100-120 beats per minute

IV fluids to improve BP, 90 systolic

Blood sugars decreased to 400s with IV insulin

Transferred to ICU

CURRENT POSSIBLE DIAGNOSES

Sepsis

Hypotension

Atrial Fibrillation (what was it triggered by?)

Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS)

Acute Kidney Injury

Thyroid Storm

THYROID GLAND REVIEW

Normal Values TSH 0.4-4.0 mlU/L

Thyroid function

Role of T3 and T4

THYROID FUNCTION

THYROID STORM

What is it?

Causes

S/S

Treatment

HYPEROSMOLAR HYPERGLYCEMIA NONKETOTIC SYNDROME (HHNS)

What is it?

Causes

Warning S/S

Treatment

RD’S ROLE IN CARE FOR MRS. W?

Interview patient for information?

Calculate nutrient needs

Determine what form of nutrients PO, G-tube, TPN, NPO w/ IV fluids?( Po support vs Enteral support at Wing)

Are there any skin wounds to consider?

Chronic or acute illness that needs to be considered?

NUTRITION ASSESSMENT

Physical Assessment Breathing

Alert

Skin appearance

Wounds present

Odor present


Current diet

Swallow status determined

IV fluids running?


BP- WNL

RR-not labored 20/minute

TEMP- afebrile

Anthropometrics

HT 67”

WT 147

KG 67

BMI 23

UBW ?

DESIRED BODY WT 135LBS- WT DOES NOT NEED TO BE ADJUSTED


Medications Humalog SS

Propylthiouracil

Inderal

Solucortef

Zosyn

Lovenox

Dilaudid

Vancomycin

Cardizem

Lanoxin

ASA

INSULIN DRIP

LABSLab value Normal range

Glucose 158 70-100 mg/dL

BUN 40 6-20 mg/dL

Creatinine 1.35 0.6-1.2 mg/dL

Est GFR 37 90-120 mL/min or > 60

Sodium 149 136-145 mEq/L

Potassium 3.9 3.5-5.2 mEq/L

Magnesium 1.5 1.8-3 mg/dL

Albumin 4.3 3.5-5 g/dL

WBC 19.9 5-10,000 mm3

Chloride 117 95-105 mEq/L

Phosphate 2.3 2.4-4.1 mg/dL

HCT 43 36-44.1 %

Hgb 14 12.1-15 gm/dL


Level One Nutritional Risk

Patients Needs include Protein: Minimum 67 grams of protein (1g/kg)

Calorie: 1675-2010 kcals (25-30kcal/kg)

Fluids: 1675-2010 ml (1ml/kcal)

PES

Inadequate oral food/beverage intake R/T DX , lethargy, DM and AKI as evidenced by patient is unable to take in PO at this time, elevated glucose, abnormal renal labs, open areas on left lower leg, heel and stage 11 skin ulcer on coccyx.

Increased nutrient needs R/T increased demand for nutrient secondary to refeeding syndrome as evidenced by labs values indicating hypophosphatemia, hypomagnesaemia, and hypokalemia.


Interventions: Inform kitchen of allergies (seafood, strawberries and chocolate)

Monitor for PO feasibility and assess for nutritional supplements as feasible

Diet Order: Diabetic/ Cardiac

Recommend once daily MVI with minerals, (zinc ,vitamin C) due to open areas

NUTRITION PROGRESS NOTE (12/30/13)

Patient could not breath on own intubated and sedated

Diet order: NPO

Med Changes: Versed, Fentanyl, Kphos, Magnesium

Current labs: BG 147, BUN and Creatinine improving, Phos 2.2 and Mag 1.6 being replaced, albumin 2.2 s/p IV fluids, H+H decreased ? Infectious process

WT: increased 15.6 LBS since admission on 12/27/13- large positive fluid balance

Abdominal CT scan showed an small bowel ileus

Interventions: Monitor labs, replace electrolytes as indicated, if unable to extubate in next 2-3 days would consider tube feeds, pending resolution of ileus

NUTRITION PROGRESS NOTE (12/31-1/2)

Diet Order: NPO

Intubation continues, weaning attempted

Med: Lasix

Labs: BG 314 w/ Humalog SS, NA WNL, Phosphate 2.0, will receive 1000 mg/day with KPHOS, K+ WNL , MG++ decreased 1.5, H+H decreased at 9.6, 29.4

WT: 161.6 LBS, (using 69 KG for calculations)

INTERVENTION (12/31-1/2) Intervention:

Tube feeding initiated Jevity 1.2 started at 30 ml/hr, tolerated without residuals

Receives 100ml water flushes four times daily

Goal Rate Jevity 1.2 60 ml/hr with 100 ml water flushes four times daily

Provide 1728 kcal (25ml/hr ABW), 80 grams protein (1.1g/kg ABW), 1562 ml free water (22ml/kg ABW)

Provide 1 tab of KPHOS four times daily (each tab: 250 mg Phos, 45mg K+, 298 mg NA), zinc, vit C

Patient at high risk for refeeding syndrome, advance tube feed by 15 ml every 8 hours as tolerated to goal rate of 60 ml/hr

Monitor wts, labs, follow refeeding syndrome, adjust water flushes as indicated

REFEEDING SYNDROME

What is it?

Causes

Treatment

Prevention


Extubated, swallow evaluation pending at this time

Diet Order: NPO, tube feed D/C’d, IV fluids D5 1/2 NS AT 100 ML/HR, ice chips are tolerated

Labs: Indicate Refeeding Syndrome NA elevated 147, K+ decreased 3.3, Phos decreased 1.9, MG++ decreased 1.6

All with supplementation

Glucose 216, A1C >15, prealbumin decreased 6.9 (wounds, sepsis, doxycycline added), H+H stable

Intervention: 1. Follow swallow evaluation/PO feasibility, labs, weight change

2. Add nutrition supplements as able (vanilla only)

3. If PO not feasible, recommend start tube feed with Jevity 1.2 at 30 ml/hr and maintain at this rate until electrolytes normalize


Patient Diet: NPO, IVF D5W 75 ml/hr

Breathing status change-currently on high flow nasal cannula

Unable to swallow today

Meeting set for consultation on transition to hospice/palliative (per patients wishes)

RD consulted for TPN recommendations

TPN 940 ml of 10% Aminosyn, 275 ml 50% Dextrose, 225ml sterile water and 250 mls 20% lipids would provide

1690 mls total volume (25ml/kg), 1344 kcals (20kcals/kg), 94 grams of protein (1.4 g/kg)

Monitor phosphate, magnesium, potassium closely, when stable increase to 25kcal/kg

3. Use standard additives, provide extra phosphate, magnesium, potassium, via IV if necessary. If sodium level is still above normal limits, consider custom additives and omit sodium chloride from TPN.

4. Follow plan of care, (SLP consult?), labs

REFERENCES

Black, J. M., Hawks, J. H., & Keene, A. M. (2001). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (6th ed.). Philadelphia: W.B. Saunders.

Crook, M., Hally, V., & Panteli, J. (2001). The Importance of the Refeeding Syndrome. Nutrition, 17(7-8), 632-637.

Diabetic hyperglycemic hyperosmolar syndrome: MedlinePlus Medical Encyclopedia. (n.d.). U.S National Library of Medicine. Retrieved February 21, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/000304.htm

International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process (4th ed.). (2013). Chicago, IL: Academy of Nutrition and Dietetics.

Mahan, L. K., & Stump, S. E. (2008). Krause's Food & Nutrition Therapy (12th ed.). St. Louis, Mo.: Saunders/Elsevier.

Manuel, A., & Maynard, N. D. (2009). Nutritional Support. British Medical Journal, 9(4), 1567-1574.

Mehanna, H. M., Moledina, J., & Travis, J. (2008). Refeeding Syndrome: What it is, and How to Prevent and Treat it. British Medical Journal, 336(7659), 1495-1498.

National Endocrine and Metabolic Diseases Information Service (NEMDIS). (n.d.). Thyroid Function Tests Page. Retrieved February 21, 2014, from http://www.endocrine.niddk.nih.gov/pubs/thyroidtests/index.aspx

Nursing 2014 Drug Handbook (34th ed.). (2014). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Pagana, K. D., & Pagana, T. J. (2010). Mosby's Manual of Diagnostic and Laboratory Tests (4th ed.). St. Louis, Mo.: Mosby/Elsevier.

Stump, S. (2012). Nutrition and Diagnosis-Related Care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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Case study - mrs .w